24904 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
BUILDING-ELECTRICAL. PERMIT NO. 24904��O
CITY OF CUPEAPPLICATION/PERMIT PLUMBING-MECHANICA
BUILDING DIVISION
N L.BUILDING PROJECT IDENFIFICATION
BUILDING ADURPSS: /�. 1�//.�} 1/ SANITARY NO. API'LICATIONSUBMTITALDATE
4D I aAM r • 1 'oh C � A�9, LOT#
A PHONE: C ;Ihll 'S NAM : ,Z'41 V I S 1
n/utr� l .h/ N/C CONTROLM
ITE '/FNGI ER: LI qq S ' qJ Cm ono Al 1a 2S-0
CONTACT: PHONE: FEE BUILDING PERMIT INFO
QTY. ELECTRIC MR I
I HG [�,T NVXII 00
1/V• o
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DEC'AIIITION APPLIANCES-REE AL LOB DESC IPDON
Qmz Iherebyaffhm that lam un
lioureadder provisi.nsofCTapm.9m
(comencing with
U1.1mreeFJOO Section �"B"a"tsion3nf the Business and Professions Coda and my license is in PANELS
Zp. Licenses Comm�m UP T0200A Lys1I`--sL�LL
y6a Dme I
Ey ARCHITECTS DECLARATION IS I:H 1 RAMPS SQ.FT,Fl.�O{p-xR AREA $/SQ.PT.
OZ-0 I understand my plans shall be used as public records. �� u J
Fqy�J LicensedPmfcssional SILECTRIC C
5 m< OWNER-BUILDER DECLARATION SPEf
SC.
yy�NJOyv 1 hereby affirm that 1 um exempt from the Cnnmu ma's License Luw for the
-vF following......(Seeien7.31.5.Business and Professions Code:Any city..coumy TEMPoL NST.
a O which rtquircs u permit m conatrva,alter,imprvve.demolish,or rendr any a,me
print to its issuance,also requires the applicant forsach permitto filen dineximmmem POW
p0 that he is licensed pursuant)rhe provisions of the Contractor's license Law(Chapter SWIELECTRIC VALUATION
aaxo� 9(commencing with Section Tl W)of Division 3 of the Business and Professions Code)
WMon or that he is exempt therefrom and the basisfor the alleged exemption.Any violation HFS-FIXTURES 76� �6
ps
4 Section 7031.5 by any applicant for a permit subjects the applicannoecivi1 pena11
t more than Five hundred dol 1...($500).
11I. ECTH .
I 0 n❑ I,asowne.oftheproperty,ormyemployeeswith wages as meirsolecompeeeaNEW HESIDENTIAEL5Q
ion, $TORIES TYPE CONSTRUCTION
a wiildoda work,and thesuuame is not imendedoroffered forade(Sec.7044,Business
and Professions Cade:The Contractors License Law does net apply to an owner of
propenyeshobuildsotlmproves thi m arra nd wbodoes aaehwe*himmli'mmmughhis
employees,provided that such improveentsarenof intendedurofferd mature.If,
O UP RIS.UNITS
howm
ever.the building or improvement is sold within one yearofcompletion,thc owner-
builder will have the burden of proving that he did am build or improve for purpose of
sale.).
❑ Las ownerofthepropety,amexclusively contracting with licensed conlrucmrsto QTY. PLUMBING PERMIT FEE ZONE APN
construct the project(Sec,7094,Business and Professions Code:)The Contmchn's —.
Licenw Lawd.mnotapplytoanownerofpropenywhobuildsorimpmvesthercon,and PERMIT ISSUANCE
whocontracts fmsueh projects with acontracwgs)licensedpursuan lothe Contractors PETER-DRAIN&VENT-WATER EA
License Law. ( ) FEE SUMMARY
❑ I am exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE SI 'EES
" SANITARY YN
Owner Date RECEIPTN
DRAINS-FLOOR,ROOF,AREA,COND.
WORKMAN COMPENSATION DECLARATION SCHOOL TA% YN
I hereby affirm that l have a certficale ofcomart toself-invure,or a cenNcite of FDUURES-PER TRAP RECEIPT
V ori Compemationlnsumnee.rat unified copy thereof(See.3800,Lab C.)which KME Y N
s\ [avert dlempl.yce'v undenhis permit. OAl F1�E GAS-I?A.SYSTEM-1 INCA OUTLETS RECEIPfN
—/ PolicyN BUILDING DIVISION FEES
Company $ GAS-EA.SYSTEM-OVER 4(EA) K s20
JZ❑ Certified co is hereby famished. X11
r Cenifted or,is filed with the city inspection division, GREASFJINDUSTRL WASTE INTERCEPTOR GRA FEZg'�.wT�
CERTIFICATE OF E%EMFFION FROM WORKERS' GREASETRAP SOILS
COMP[N4SATION INSURANCE
('This.ectionn«dnmb a mpleredifthepemtitisforme hundrtddollam($100) SEWER-SANITARY-STORM EA,20 G FEF.
tor less.)
I certify that in tbeperformwmofthe work forwhichnit thispertisiimed,l shall WATER HEATER WNENT/ELECTR
not employ any person in any manner so as in become subject to the Workers' PAI Z LH
Z Cempervallma Le—itf Calumin. Data WATER SYSTEM/IREATING Data Receipt
Applicant
Z0 NOTICE TO APPLICANT:IL after making this Cenificete of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL: (toGv
r V) become subject The Worker's Compensation provisions of the Labor Code,you must PING FEE
[a^ forthwith comply with such provisions or this permit shall be deemed revoked, .�
w (] CONSTRUCTION LENDING AGENCY ICFEE
5 1 hereby affirm that is a construction lending agency for the performance of
U O the work for whichthis permit is issued(Sec.3097,Civ,C.) T E RIC FEE
V. (r IsnJels Name
0 U Lenders Address QTY. MECHANICAL PERMIT FEE G
U I certify that I have mad this application and smm that Ne above information is MECII PF.E
>a LII correct I agree to comply with all city and county ordinances and,stum laws relating to PERMIT ISSUANCE
t� V) buil ding construction.and hereby authorize mprescntativesofthis city to enterup.n the CONSTRU AX
U Z abo mentioned prope.ry far inspection purposes. ALTERORADDTOMECH.
We)agam to save,indemnify and keep bo.mless the City of Constrain.against
inti' es,judgmems,cot.and expenses which may irony wayaontra.gamitsaid City AIR HANDLING UNIT(TO 10,WXI CFM)
in a cc ft . tingofthisparmit PIR HANDLING UNIT(OVER 10,000 CFM)
ign of Apel mrector Dan, EXHAUST HOOD(W/DUCD PAID
1//1 H \BOGUS MATERIALS DISCLOSURE HEATING UNIT(TO IN,"BTU) Dam Receiptp
Will Ne a�pY1 orfutum building mcupantammnr handle havuders m.mrid
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 10(t BTU) TOTAL:
Cale,Section 25532(a)7
CI Yes Nn VENTILATION FAN(SINGLE HPSID) 110
S7fpA DATE
Will theapplieantmfmumbuildingmcupantuseequipmenmrdevias whichemit BOILER-COMP(JHPOR 100,0000TU)
zmdom dr eommninantx as defined by the Bay Arc.Air Quality Management BOILER-COMP(OVER 100,1X10 BTU)
tViCl? n
❑Yea )(No NEW RESIDENTIAL MECH.—SQ.FT. t Lk�Yo '�H�'pvJ�`
I have mad the hmeNnus mations 5505.25533 under Chapter 695 of the !% `C V�KJI/
California Health&Safay Cute,Sections 25505.25533 and 25534. I underswnJ that
ift uilding does not currently have a mount,that it is my responsibility,to notify the V
%c
P t f" ts hich man h met prior to issuance of a Can'tome of
O caahmi.il e n D m ( ISSUED BY:
OFFICE